Pages

Monday, June 13, 2011

Rites of Passage

There are the ones you get excited about.Turning 16 – the freedom gained from driving a car.Turning 21 – finally being able to drink legally.And there are the not-so-exciting ones.

When I went to my OB for the first time in few years a couple of weeks ago for a routine check-up, as I was leaving, she said, “Oh, Gizabeth.We need to schedule you for a screening mammogram.”She must be mistaken, I thought.I am eternal youth.I am 37.I informed her of this, and she said, “Screenings are recommended between the ages 35 and 40.”Hitting this particular mile marker is a little depressing.

You might think, since I am a doctor and all, that I had an actual clue about the process of getting a mammogram.I didn’t.Although I spent a week on radiology, quickly determining that me sitting in a dark room for a job might not work since I always wanted to fall asleep, and a week on breast oncology surgery, I have never witnessed a mammogram.I saw one of the breast radiology specialists describe it once, using her hands and her own breast to illustrate (through her clothing), when answering an oncologist’s question about the orientation difference between looking at a mammogram and MRI, but I still didn’t really get it. What would it be like?Since no one other than myself has touched my breasts (for self-breast exams and washing, of course, this is a G rated article, well maybe PG) for quite some time, I even wondered if it might be a little exciting.I was a little relieved, for my own sanity, to discover that it was not – far from it, in fact.I know many reading this have had a mammogram, but for those who have not, let me describe it to you.

They called me back into a cubicle to put on a paper gown.There was an advertisement on the wall claiming that if you went back to the front desk to pay an extra few bucks you could get this foam pad that was statistically proven to make the mammogram experience more comfortable.What about a mammogram experience requires a foam pad, I wondered, since there were no visuals or an explanation provided?Was it something to lay your head upon?I decided not to ask.I was going to go in cold turkey.I’m pretty tough.There was also an instruction card asking you to remove deodorant or powder from your breasts with baby wipes provided.Who puts deodorant or powder on their breasts?Is this something I missed in adolescent hygiene?

I was escorted into a dark room and saw what reminded me a little of a giant vertical George Foreman grill, minus the ridges, at about breast level.It was on a large post and could be manipulated up and down as well as rotate back and forth.The thankfully female tech looked at my breasts.“I think we need to switch out the tray.”She pulled off a large tray underneath the metal sandwich, I mean breast press, and reached down to the bottom rung of a shelf, grabbing a much smaller tray (haha, for the runts, I thought).One at a time, she used her hands to manipulate my breasts into very stretchy shapes I did not know were possible and squished them tightly between the metal plates, which she was closing in on my breast with electronic manipulation.All the while I was being instructed to “angle your head back this way,” “No, wrap this arm around the top of the machine that way,” and “push your shoulder back a little more” and I was oddly reminded of yearly school pictures.At one point she said “No, put your arm over here, I don’t want this to be awkward for you.”I laughed out loud, and told her, “I know you do this many times a day, but there is nothing to me about this situation could not be called awkward.”She smiled, “I guess you are right.”

She was nice.We chatted about kids and concerts throughout the process.When she had each breast sufficiently pan-caked to her preference, she instructed me to hold my breath so she could take a picture.When we were done, she said, “Do you mind if I get a picture of your left breast again?I didn’t get the nipple in profile and it is so much better that way.”I looked up at the radiographic images she had put on a light box, and gasped internally.I see these all the time in conference, but they were mine, and they looked so beautiful.I wanted to ask if I could take one home with me, but that would sound weird, and it’s not like it’s something you can just frame or display on the fridge and not get questions.The one with the nipple profile did look much better – the side without a nipple looked a little malformed, so I agreed.

I got called back for additional images the next day – luckily I was prepared by learning from a friend that this is common, not to worry – they just need to get a really good baseline to establish any asymmetry as most likely benign, and I was glad for her reassurance.But this did not help me from having a tiny panic attack in the waiting room cubicle once again – still did not buy the foam cushion, but at least I understood it now – because I have so much to live for, these days.So I was relieved when after more mammograms and then an ultrasound exam the radiologist, who seemed very surprised to see me as his patient – the name change is still throwing people off – assured me that everything looked all right.“We’ll see you in three years.”Whew.

had my first at 28 for a lump, turned out to be a cyst (phew!), the US was much better. The breast squishing is Not a pleasant experience. My mother in law still insists that mammograms made her breast deflate and long(er) and will not consider that this tends to happen at 70 yrs of age..anyway, another story all together).Wonder if the MRI is more pleasant and if insurance will cover costs for screening - anyone know? Friend of mine just had a double mastectomy at 42, i think we need to start screeninig earlier, not later, certainly not at 50

I had this same discussion when I went in for my annual female exam this month. Funny, I guess this shows the difference between us. I whipped out the old USPSTF argument, and told the resident I am not a good candidate for early mammogram.

He walked out of the room, discussed it with a colleague, and came back in saying the USPSTF was "stingy" in its recommendations. I said yes, they are, and I tend to agree with them, being non-interventionist minded myself. He walked out again,and came back in with a prescription for a breast ultrasound. Sigh, I may get it.

Anyway, I loved your description. I do think the mammograms can look beautiful, and I am sure yours looked particularly beautiful to you. You describe the experience as something more than a painful annoyance, which is the way I usually hear it remembered. Now I may get a baseline at 40.

TJ - I know the breast radiologists at our institution and they are very good. I see the specimens. I realize that false positives can happen, but as someone who looks at hundreds of breast cases a year, many of them women under 40 - I have an extra edge of paranoia that makes me happy to follow the recommendation of my OB. The worst is when you pick up a slide, see the age - some down in 20's - and notice lactating ducts right next to Grade 3 cancers. I realize these are outliers, and many have family history, but still.

Cardiomom - I don't know the answer on screening mammograms. I have not yet written a check. Hopefully someone else can chime in.

Christie Critters - that sounds like a sick variation of twister!

MomTFH - thank you! It really wasn't too bad. Good luck with your decision. Sounds like Bette and Hil all over again - made me smile.

I saw one of the breast radiology specialists describe it once, using her hands and her own breast to illustrate (through her clothing), when answering an oncologist’s question about the orientation difference between looking at a mammogram and MRI, but I still didn’t really get it.

>>as someone who looks at hundreds of breast cases a year, many of them women under 40 - I have an extra edge of paranoia that makes me happy to follow the recommendation of my OB>>

Many of the samples you see, especially in very young women, are obtained after a lump is discovered and/or a diagnostic mammogram. Also, as you probably know, early discovery does not equal longer survival time, and some of the really nasty tumors (like inflammatory breast cancer) grow so quickly that annual exams frequently miss the tumor entirely at an early stage. Breast cancer, as you well know, is not just one disease, and mammography is a blunt screening instrument at best, IMO.

Knowing all of this, and having looked at the numbers, I'll take my chances. I'd refuse ultrasound and MRI, too.

I did make a well-informed choice; I'm following the USPSTF recommendations mentioned by MomTFH.

I'm much more concerned about cardiovascular disease than breast cancer, though I've never been overweight and am a lifelong non-smoker. Three of my grandparents died of cardiovascular disease, though one also had Alzheimer's (can't do anything about that, AFAIK).

My former PCP pressured me to go for mammograms starting at age 40 as well as continued annual Pap smears (despite monogamous relationship and long history of normal tests) and annual basic bloodwork (of questionable utility for a healthy person). This made me very uncomfortable as I felt her frustration with my repeated polite refusals distracted her from paying sufficient attention to what is most likely to kill me, based on both family history and overall population: cardiovascular disease. I felt like she was checking off boxes on a not-very-well-thought-out list rather than looking at me as an individual. So I dropped her. My new PCP and I agree on priorities for my routine healthcare and I listen to her recommendations. Best of all? My borderline "white coat" hypertension has all but disappeared since I've switched physicians. Coincidence? I think not.

They say that doctors make the worst patients - and I certainly fit that rule. Haven't checked in on my own PCP and I've had him 8 years. Haven't taken a sick day in 6 years. One of my partners sat on a stomachache all day and ended up with a ruptured appendix. I did just get the highest rating for life insurance after giving them my bodily fluids to analyze, so I guess that is a good thing.

For anyone reading this post - ACOG came out with new guidelines in July of 2011. They hadn't changed since 2003 (dinosaurs). Now they recommend yearly mammograms starting at 40, based on current literature.

Mothers in Medicine is a group blog by physician-mothers, writing about the unique challenges and joys of tending to two distinct patient populations, both of whom can be quite demanding. We are on call every. single. day.

Disclaimer

No content of this blog should be taken as medical advice. Any references to patients have been altered to maintain confidentiality. Content and links on personal blogs listed on the blogroll are not vetted or monitored and do not represent endorsements by Mothers in Medicine.